New Client Form - Grace Park Animal Hospital

Name *

First

Last

Driver License # *

Spouse's/Significant Other's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Number *

Home Phone

Work Phone

How did you hear about us?

If referred by a friend/relative, whom may we thank?

About your Pet

Pet's Name *

Species *

Dog
Cat

Gender *

Female
Spayed Female
Male
Neutered Male

Breed *

Color *

Date of Birth or Approximate Age *

Please list any regular medications your pet is on:

Please list any chronic health problems we should be aware of:

Previous veterinarian’s contact information so we can obtain medical history for your pet(s).

Previous Veterinarian's Phone Number

Acknowledgement

Your signature on this form indicates your understanding and agreement to the following policies:

Payment Policy

Payment is due at the time services are rendered. We will gladly prepare a written estimate if you desire (please ask one of our team members). We accept cash, in-state personal checks with in-state driver’s license, Visa , Mastercard, Discover, American Express, and Care Credit. There is a $35.00 service charge for returned checks. Unpaid balances are subject to interest (18% APR), and a monthly statement & handling fee of $3.00. Unpaid balances greater than 90 days will be turned over to a collections agency and subject to a $35.00 administrative fee as well as the collection agency fees.

Vaccine/Parasite Policy

To prevent the spread of infectious diseases, all patients staying in the hospital must be current on all vaccines (rabies, distemper, and bordetella (dogs only)) and free from internal parasites (annual fecal examination required) and external parasites. If my pet is not current, or current records are unavailable, I understand that my pet will be examined and the appropriate vaccines and parasite treatment will be given while staying in the hospital. The examination, vaccines, and/or parasite treatment will be in addition to all other charges. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice.

Signature *

Clear Signature

Signed by (type name): *

Date Signed *

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About your Pet

Acknowledgement

Payment Policy

Vaccine/Parasite Policy

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